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GET THIS BOOK Committee on Offshore Oil and Gas Safety Culture; Policy Studies; Transportation
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Beyond
Compliance
Strengthening the Safety Culture
of the Offshore Oil and Gas Industry
NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils
of the National Academy of Sciences, the National Academy of Engineering, and the
National Academy of Medicine. The members of the committee responsible for the report
were chosen for their special competencies and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to the pro-
cedures approved by a Report Review Committee consisting of members of the National
Academy of Sciences, the National Academy of Engineering, and the National Academy
of Medicine.
TRB Publications Staff: Rona Briere, Editor; Javy Awan, Production Editor; Juanita
Green, Production Manager; Mary McLaughlin, Proofreader; Jennifer J. Weeks, Manu-
script Preparation; Alisa Decatur, Word Processing Support
Design and page composition by Beth Schlenoff, Beth Schlenoff Design
Cover photograph: Larry Lee/Getty
ISBN 978-0-309-44129-2
The National Academy of Engineering was established in 1964 under the charter of the
National Academy of Sciences to bring the practices of engineering to advising the nation.
Members are elected by their peers for extraordinary contributions to engineering.
Dr. C. D. Mote, Jr., is president.
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in 1970 under the charter of the National Academy of Sciences to advise the nation on
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tions to medicine and health. Dr. Victor J. Dzau is president.
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Learn more about the National Academies of Sciences, Engineering, and Medicine at
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Transportation, and other organizations and individuals interested in the development
of transportation.
marine Board
James C. Card (Vice Admiral, U.S. Coast Guard, retired), Independent
Consultant, Chair
Mary R. Brooks, Dalhousie University, Vice Chair
Edward N. Comstock, Independent Consultant (retired from Raytheon and
Naval Sea Systems Command)
Elmer P. Danenberger III, Independent Consultant
Samuel P. De Bow, Jr. (Rear Admiral, National Oceanic and Atmospheric
Administration, retired), Lynker Technologies
Thomas J. Eccles (Rear Admiral, U.S. Navy, retired), USJ-IMECO Holding
Company
Martha R. Grabowski, LeMoyne College
Jeanne M. Grasso, Blank Rome, LLP
Stephan T. Grilli, University of Rhode Island
John M. Holmes (Captain, U.S. Coast Guard, retired), Independent Consultant
Thomas A. Jacobsen (Captain), Jacobsen Pilot Service, Inc.
Donald Liu, NAE, American Bureau of Shipping (retired)
Richard S. Mercier, Texas A&M University
Edmond (Ned) J. Moran, Jr., Moran Towing Corporation
Ali Mosleh, NAE, University of California, Los Angeles
John W. Murray (Captain), Hapag-Lloyd USA, LLC
Karlene H. Roberts, University of California, Berkeley
Richard D. Steinke, Moffatt & Nichol Engineers
Peter K. Velez, Peter Velez Engineering, LLC
Richard D. West (Rear Admiral, U.S. Navy, retired)
Beyond
Compliance
Strengthening the Safety Culture
of the Offshore Oil and Gas Industry
The offshore oil and gas industry in the Gulf
of Mexico is among the most developed in
the world. It provides thousands of jobs in
the Gulf Coast region and supplies a sizable
portion of the U.S. energy requirement. Oil
production in the Gulf of Mexico is expect-
ed to account for 18percent and 21 percent
of total forecast U.S. crude oil production in
2016 and 2017, respectively, even as oil prices
remain low.
Drilling offshore for oil and gas can,
however, be a dangerous business. Logistical,
oceanographic, operational, and economic
challenges complicate deepwater exploration
and development. The number and variety
of contractors operating on a single facility
can increase the challenges associated with
sustaining a common safety culture, manag-
ing personnel effectively, and carrying out
the responsibility for maintaining safe work-
ing conditions.
inga spenCe/alamy
Copyright National Academy of Sciences. All rights reserved.
Beyond Compliance: Strengthening the Safety Culture of the Offshore Oil and Gas Industry
2 B e yo n d Co mp l ia nCe
u.s. CoasT guaRD phoTo By peTTy offiCeR 3RD Class ann maRie goRDen
Incidents with extensive repercussions, such as the Macondo well
blowout of 2010, are unlikely. Yet when they do occur, they can have
severe consequences for offshore workers, people in the communities that
support the oil and gas industry, those whose livelihoods are affected, the
assets of the operator and its contractors, the environment, and the indus-
try as a whole. The Macondo well blowout led to an explosion and fire on
the Deepwater Horizon drilling rig that resulted in the deaths of 11 crew
members, injuries to others, and the spilling of an estimated 3.19 million
barrels of crude oil into the Gulf of Mexico. In the end, the incident will
cost BP more than $30 billion in fines, penalties, operational response,
and liabilities.1 The magnitude of the disaster and its substantial economic
impacts on the Gulf Coast region as a result of lost revenue, profits, and
wages have led to intense public scrutiny of the safety of offshore drilling
and production.
Prior to the Macondo event, many in the industry found it difficult
to imagine an accident in the United States that would result in a major
oil spill, loss of lives, injuries, and the sinking of the rig. This point is il-
lustrated by the aftermath of the 2009 blowout and fire on the Montara
wellhead platform and subsequent oil spill in the Timor Sea (northwest of
the Western Australia coast). Following this incident, many of the public
1
According to the Wall Street Journal (April 26, 2016), BPs total bill is more than $56 billion to date
and continues to increase.
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 3
statements from the U.S. oil and gas industry focused on explaining why a
Montara-like blowout could not happen in the United States, rather than
expressing the industrys intent to learn more about the Montara incident
and its causes and share that knowledge industry-wide. As it happened,
the root causes of the Macondo and Montara blowouts were similar: both
involved failures of management systems and processes. Had industry
made a greater effort to understand the causes of the Montara event, the
suspension of the Macondo well might have been managed better, with
less damage.
Multiple investigations of the Macondo well blowout, rig explosion,
and oil spill attributed the cause of the blowout to a series of mistakes
made by the operating company, the drilling contractor, and the contractor
for the cementing job. Ultimately, those mistakes are indicative of system-
atic failures in risk management, and call into question the safety culture
of the offshore oil and gas industry. Indeed, the various investigations led
to a common conclusion: that a lack of process safety and deficient safety
culture were primary causes of the accident. This consensus conclusion
signaled a significant change in how the causes of such catastrophic ac-
cidents are understood.
philip goulD/geTTy
dreampictures/getty
Copyright National Academy of Sciences. All rights reserved.
Beyond Compliance: Strengthening the Safety Culture of the Offshore Oil and Gas Industry
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 5
tegic plan for achieving safety and environmental objectives, and creating
an independent industry safety organization. The report then describes
the challenges entailed in implementing change in offshore safety culture,
along with strategies for overcoming those challenges. The final section
addresses assessment of progress in safety culture to facilitate improve-
ment. The discussion herein is based on the main findings, conclusions,
and recommendations of the National Academies committee. Readers
interested in additional information on these topics should refer to the full
report.
2
The committees work was supported with funds designated for the National Academy of Sciences
as a community service payment arising out of a plea agreement entered into between the United
States Attorneys Office for the Eastern District of Louisiana and Helmerich & Payne International
Drilling Company.
3
Strengthening the Safety Culture of the Offshore Oil and Gas Industry, available at http://www.nap.
edu/catalog/23524/strengthening-the-safety-culture-of-the-offshore-oil-and-gas-industry.
6 B eyo n d C o m p lia n Ce
In the many decades since the oil and gas industry began working along
the coastline and, ultimately, moved offshore to explore for and produce oil
and gas, occupational safety appears to have improved through the efforts
of companies, industry associations, and regula-
tors. The offshore environment did not start out
as a safe one in which to work. Initial ad hoc and
experimental designs for drilling from vessels and
platforms in shallow water resulted in overturned
vessels, fires, explosions, blowouts, and extensive
loss of life in the 1950s and 1960s. Inconsisten-
cies in reporting and reporting requirements
DoD phoTo By spC 2nD Class JonaThen e. Davis make it impossible to assess accident rates during
the early years as companies moved farther offshore, but a series of di-
sasters during this period illustrated the risks and motivated action by
industry and government.
From the mid-1960s through the 1990s, the industry began to work
collectively to solve design and equipment problems. Industry associations
such as the American Petroleum Institute (API) and the Offshore Opera-
tors Committee (OOC) advised the federal government on changes that
would improve safety, developed and issued a series of recommended prac- DoD phoTo By spC 2nD Class JusTin sTumBeRg
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 7
8 B e yo n d Co mp l ia nCe
Characteristics of a Strong
Safety Culture
4
Reports issued by the National Commission on the BP Deepwater
Horizon Oil Spill and Offshore Drilling; the National Academy of
Engineering and the National Research Council; the U.S. Coast Guard;
and the Bureau of Ocean Energy Management, Regulation, and Enforce-
ment Joint Investigation Team.
enDosToCk/DReamsTime
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 9
10 B eyo n d C om p lia n Ce
Once the industry has agreed upon steps to take to achieve safety and
environmental objectives, each organization involved in the offshore oil
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 11
nine Characteristics
of a Strong Safety Culture
leadership commitment to safety values and actionslead-
ers demonstrate a commitment to safety and environmental stewardship in
their decisions and behaviors. leaders visibly demonstrate this commitment
through how they allocate resources within the organization and prioritize
safety relative to production.
anTaRTis/DReamsTime
Copyright National Academy of Sciences. All rights reserved.
Beyond Compliance: Strengthening the Safety Culture of the Offshore Oil and Gas Industry
12 B eyo n d C om p lia n Ce
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 13
14 B e yo n d Co m p lia n Ce
undertake new and different initiatives. Goals for offshore safety culture
shared between the industry and regulators would help define new safety
culture activities, such as coaching, sharing of lessons learned, and inde-
pendent safety culture assessment. Currently, a considerable imbalance
favors traditional compliance activities by regulators over activities intend-
ed to help strengthen safety culture, and the existing offshore compliance
culture reflects this imbalance. If the offshore oil and gas industry is to go
beyond compliance, changes in the regulators policies will be necessary.
The industry sees its regulators collectively as the government, but when
introducing safety culture initiatives, regulators will need also to assume
the role of participants in the effort to establish and maintain a strong
safety culture across the industry. Ideally, the overall role of the regulators
is to ensure that the operating companies have systems in place to opti-
mize safety performance.
noaa (3)
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 15
niColas Russell/geTTy
dence-based decision-making process that involves reporting of accurate
and complete data, analysis of causes and trends, and sharing of the data
across the industry and with the regulators. More important, the industry
and the regulators should go beyond ideas and possibilities and develop
concrete plans for execution.
16 B eyo n d C om p lia n Ce
RiCk loomis/geTTy
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 17
gas industry institute would need to be entirely free from other interests
and agendas and separate from API. The institute would also need to
secure an industry-wide commitment to rigorous auditing and continuous
improvement. In effect, all companies operating on the Outer Continental
Shelf would participate in the safety institute.
overcoming the
Challenges to Change
18 B e yo n d Co m p lia n Ce
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 19
culture are discussed below, along with approaches for overcoming them.
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Strengthening the Safety Culture of the Offshore Oil and Gas Industry 21
CaRolyn Cole/geTTy
22 B e yo n d Co m p lia n Ce
culture will invite people to action. They will see a future desirable enough
to change the present to achieve it.
Leaders who successfully implement an effective safety culture are
highly visible role models who live safety as a value, consistently demon-
strate the importance of safety-related behaviors, and instill the courage to
change in others. They focus not only on getting results but also on getting
results in the right way and behaving in accordance with the value of a
strong safety culture. Workers, supervisors, and managers will not speak
up about safety issues or be willing to stop work unless they believe their
leadership will support them. Senior leaders may believe they are willing
to support such actions, but if there is no precedent (or, worse, a history
of negative reactions) and employees are afraid to even try, there is no
opportunity to reinforce safe behaviors. Leaders need to be proactive with
their messages and actions and ensure that no learning opportunity goes
to waste.
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 23
aRnulf husmo/geTTy
john barratt/getty
Copyright National Academy of Sciences. All rights reserved.
Beyond Compliance: Strengthening the Safety Culture of the Offshore Oil and Gas Industry
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 25
ous national cultures whose languages are not English and whose safety
attitudes and practices may differ both from each other and from U.S.
approaches. Some foreign-flag drilling rigs move around the world with
long-term, non-American crews. These crews may have consistent exper-
tise and a coherent rig culture (which may be very safe), but this culture
may vary from that of the operator. Even within a single national culture,
such as that of the United States, cultural and status differences exist
among professional groups (e.g., engineers versus operators versus manag-
ers), hierarchical levels, generations of workers, and local sites.
26 B e yo n d Co m p l ia nCe
persists, however, as
a result of both the
industrys heritage
and the rapid growth
in new operators and
contractors.
In this industry,
moreover, as in many
others, there is an
existing culture of
individual blame for
philip goulD/geTTy noncompliance with
rules. Unfortunately, a blaming culture often works against a reporting cul-
ture. Thus workers are reluctant to report near misses or small accidents,
which can be precursors of larger problems. In addition, problems may
be hidden to avoid paperwork; please the boss; receive bonuses; or avoid
management attention, peer annoyance, and regulatory enforcement. Even
when reported, the incidents that garner attention are often those involv-
ing minor personal injuries, transportation incidents, and spills (because
they occur most frequently) rather than gaps in process safety that could
be precursors of major accidents.
Like most industries, the oil and gas industry as a whole does not
consistently engage in systems thinking in which the interrelationships
among events and practices are considered. Problems may be seen as one-
off and each installation as unique. An operator may share lessons learned
internally but be less inclined to share them with another operator. The
tendency is to focus on immediate, proximal causes (such as human error)
rather than systemic causes, including culture. Historically, fixes have been
devised with little understanding of how they will be implemented and
validated or what unintended consequences they might have.
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 27
goal setting and drives progress toward operations free of incident (includ-
ing personal and process safety accidents, near misses, and nonconfor-
mances). Plans are developed to close identified gaps, actions are taken,
and results are reviewed for validation and learning purposes. Developing
and sustaining a strong safety culture requires that all members of the
workforce be competent relative to their assignments and accountable for
established safety processes.
Although senior leadership support is essential, positive safety changes
also require the involvement of field supervisors and workers who are
dedicated to safety improvement and equipped to achieve it with both
authority and resources. The very concept of safety culture implies com-
mitment and participation throughout the organization.
Given the demonstrable progress being made toward strengthening
safety culture in many parts of the industry, it is desirable to leverage indi-
vidual successes to help accelerate progress industry-wide. Industry groups
and regulators can help disseminate success stories and lessons learned.
Operators can encourage and advise their contractors, contractors can
encourage and advise their subcontractors, and vice versa. This industry
u.s. CoasT guaRD phoTo By peTTy offiCeR 3RD Class paTRiCk kelley
28 B eyo n d C om p l ia nCe
can look to the success of the nuclear power industry in creating a strong
industry-led organization (the Institute of Nuclear Power Operations) to
set standards and facilitate knowledge sharing.
auRoRa open/geTTy
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 29
keiTh WooD/geTTy
30 B eyo n d C om p lia n Ce
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 31
32 B e yo n d Co m p l ia nCe
Why Is It Important to
Bsee
Measure Safety Culture?
It is important for organiza-
tions to conduct periodic
assessments of their safety
culture for the following
reasons:
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 33
Bsee
34 B eyo n d C om p lia n Ce
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 35
eRiC hinson/DReamsTime
Copyright National Academy of Sciences. All rights reserved.
Beyond Compliance: Strengthening the Safety Culture of the Offshore Oil and Gas Industry
36 B e yo n d Co m p l ia nCe
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 37
38 B eyo n d C om p lia n Ce
always been valued. In addition, workers may fear that reporting safety
issues or making negative comments could jeopardize their job, create con-
flict in the workplace, increase workload for themselves or their coworkers,
and fail to result in improvements. Front-line employees need a feeling of
psychological safety to be willing to disclose difficult conditions or events
without fear of being embarrassed by their peers or punished by their man-
agers. This feeling is the foundation of a reporting culture and the starting
point for improvement. Psychological safety can be enhanced by messages
from legitimate leaders, as well as by an open, fair, and participative process.
Companies need to build trust in management and provide positive incen-
tives to encourage reporting and participation in the learning process.
Front-line employees and all key stakeholders also need to stay in-
volved, or at least be informed on an ongoing basis, after the safety culture
assessment has been completed. Many organizations fail to communicate
the results of the assessment back to employees, who are likely to conclude
that the assessment was a ceremonial exercise carried out to comply with
external demands and that no meaningful changes will result. Psychologi-
TeRRy mooRe/alamy
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 39
Bsee
cal safety is important not just for front-line employees but for all partici-
pants, including senior management. Companies are understandably cau-
tious about producing reports that expose them to regulatory sanctions
or to legal actions asserting negligence. Making safety a priority entails
executives showing leadership by supporting the flow of information
necessary for organizational learning, because the cost of hiding problems
is likely to be higher in the long run than the cost of facing them as early
on as possible.
Monitoring of safety culture requires more than an assessment every
2 years through a survey. Periodic surveys and audits are most helpful
when paired with other, more regular (monthly or quarterly) assessments.
Larger organizations often have a dashboard of indicators that are used
for various management concerns, including productivity, cost, environ-
ment, human relations, and safety. Increasingly, safety culture is a part
of such a dashboard, with multiple indicators being examined regularly.
These indicators may include codes for safety outcomes, near misses,
problem reports, incident investigation results, employee concerns and
suggestions, management walkarounds, observations of prejob briefings
and after-action reviews, and union concerns.
The safety culture assessment process also serves as an opportunity
to engage the organization in a set of conversations and change activities
that could have a major beneficial impact on the culture itself. An effective
40 B e yo n d Co m p l ia nCe
unlisTeD images/alamy
Strengthening the Safety Culture of the Offshore Oil and Gas Industry 41
Acknowledgments
This publication is an abridgment of Strengthening the Safety Culture of the
Offshore Oil and Gas Industry, a report released in 2016 from the National
Academies of Sciences, Engineering, and Medicine. Raymond A. Wassel,
Stephen R. Godwin, and Camilla Y. Ables of the National Academies staff
prepared the abridgment, which was reviewed for consistency with the main
report by John S. Carroll, Elmer P. Danenberger III, Nancy T. Tippins,
and Peter K. Velez, members of the authoring committee. The review was
overseen by Susan Hanson (NAS), Clark University (emerita).
42 b eyo n d c o m p l ia n c e
ISBN 978-0-309-44129-2
90000
9 780309 441292